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Section 1 of 2
Gifted Education Services Student Self-Report /Referral Form
Please complete this form and return it to the Gifted Education Teacher at your school.  Your insight into your own strengths and interests is an important part of determining the services and programming for you. Your input will help us determine whether you would be served in the Gifted and Talented (GT) / Talent pool program. Should you qualify for an Advanced Learning Plan (ALP) through the GT program, your input will also be critical in developing and updating your annual ALP.  
Student School of Attendance
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Name:  
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Date of Birth:  
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Address:  
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Parent Email:  
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Phone #
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Grade Level and School
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Suspected area of giftedness (please check all that apply) Academic Areas:
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General Intellectual Ability
Science
Reading
Social Studies
Writing
World Language
Math
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or
add "Other"
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Other Areas:  
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Creative/Productive Thinking
Music
Psychomotor Ability (athletics)
Performing Arts
Visual Arts
Leadership Ability
Dance
Other Areas
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1.
Other Areas
2.
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Creative/Productive Thinking
Music
Psychomotor Ability (athletics)
Performing Arts
Visual Arts
Leadership Ability
Dance
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Section 2 of 2
Gifted Education Services Student Self-Report /Referral Form
Directions: Read each statement and decide how often you exhibits each behavior.
0 = never 1= rarely 2 = expected amount 3 = more than expected 4 = much more than expected

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Gifted Education Services Student Self-Report /Referral Form
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Question Type
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0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
I have a desire or enthusiasm to learn.
I am persistent in pursuing or completing self-selected tasks.
I have intense, sometimes unusual, interests.
I am a self-starter.
I pursue some activities unceasingly.
I am bored or frustrated in school.
I am highly capable but do not have good grades.
I begin an assignment but don’t complete it or turn it in.
I am highly expressive with words, numbers, OR symbols.
I create new designs or inventions.
Rows
1.
I have a desire or enthusiasm to learn.
2.
I am persistent in pursuing or completing self-selected tasks.
3.
I have intense, sometimes unusual, interests.
4.
I am a self-starter.
5.
I pursue some activities unceasingly.
6.
I am bored or frustrated in school.
7.
I am highly capable but do not have good grades.
8.
I begin an assignment but don’t complete it or turn it in.
9.
I am highly expressive with words, numbers, OR symbols.
10.
I create new designs or inventions.
11.
Add row
Columns
0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
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Answer key
(0 points)
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Question Type
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0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
I have a large storehouse of information on a particular topic.
I have an exceptional ability to retain and retrieve information.
I pay attention to details.
I question, experiment, and explore.
I have been told that I ask unusual questions for my age.
I play around with ideas.
I have been told that I am keenly observant.
I see unusual and diverse relationships between ideas, concepts and objects.
I can think things through in a logical manner.
I am a critical thinker.
Rows
1.
I have a large storehouse of information on a particular topic.
2.
I have an exceptional ability to retain and retrieve information.
3.
I pay attention to details.
4.
I question, experiment, and explore.
5.
I have been told that I ask unusual questions for my age.
6.
I play around with ideas.
7.
I have been told that I am keenly observant.
8.
I see unusual and diverse relationships between ideas, concepts and objects.
9.
I can think things through in a logical manner.
10.
I am a critical thinker.
11.
Add row
Columns
0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
Add column
Answer key
(0 points)
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Question Type
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0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
I produces many ideas.
I have original ideas and/or create original products.
I have been told that I have wild, seemingly silly ideas.
I am highly curious and may have been told that I ask a lot of questions.
I have a good sense of humor (which some people may think is hostile or mean).
I see the unusual (may recognize relationships among seemingly unrelated areas of knowledge).
I am uncommonly emotional.
I am very sensitive to sounds, smells, sensations in general.
I can have very strong, even extreme, responses to things.
I constantly move or gesture.
Rows
1.
I produces many ideas.
2.
I have original ideas and/or create original products.
3.
I have been told that I have wild, seemingly silly ideas.
4.
I am highly curious and may have been told that I ask a lot of questions.
5.
I have a good sense of humor (which some people may think is hostile or mean).
6.
I see the unusual (may recognize relationships among seemingly unrelated areas of knowledge).
7.
I am uncommonly emotional.
8.
I am very sensitive to sounds, smells, sensations in general.
9.
I can have very strong, even extreme, responses to things.
10.
I constantly move or gesture.
11.
Add row
Columns
0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
Add column
Answer key
(0 points)
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Question Type
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0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
I behave in ways or make comments that don’t seem to make sense to others.
I have an intense fantasy life (may make up/tell stories and/or worry about things others find unreasonable).
I am highly concerned about the sufferings or misfortunes of others.
I am highly concerned about people being treated or acting unfairly.
I have an ability to understand and share the feelings of others.
I am highly concerned with right and wrong behavior and the goodness or badness of human character.
I feel “different” socially.
I worry about my purpose, existence, fitting in, and/or the future.
I am overly self-critical.
I need a creative outlet.
Rows
1.
I behave in ways or make comments that don’t seem to make sense to others.
2.
I have an intense fantasy life (may make up/tell stories and/or worry about things others find unreasonable).
3.
I am highly concerned about the sufferings or misfortunes of others.
4.
I am highly concerned about people being treated or acting unfairly.
5.
I have an ability to understand and share the feelings of others.
6.
I am highly concerned with right and wrong behavior and the goodness or badness of human character.
7.
I feel “different” socially.
8.
I worry about my purpose, existence, fitting in, and/or the future.
9.
I am overly self-critical.
10.
I need a creative outlet.
11.
Add row
Columns
0 - never
1 - rarely
2 - expected amount
3 - more than expected
4 - much more than expected
Add column
Answer key
(0 points)
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Would you be able to provide any of the following related to your ability?
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Portfolio of work in gifted area
Examples of exceptional performance
Record of contests, competitions, and/or juried performances in which your child has participated
Add option
or
add "Other"
Answer key
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Do you believe that your grades in school accurately reflect your ability? Why or why not?
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Answer key
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Do you believe that you have good study habits and organizational skills? Why or why not?
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Answer key
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Do you have any further observations or comments related to your performance, ability, interests, or perceptions about learning/school?